by Bhavin Doshi

A GALS screen is an examination used by doctors and other healthcare professionals to detect locomotors abnormalities and functional disability relating to gait, arms, legs and the spine

Locomotors Examination Ggait Aarms Llegs Sspine

Why use GALS? To describe a rapid screening examination of the musculoskeletal system - termed the ‘GALS’ screen To overview how abnormal joints are assessed during the physical examination

GALS Screen – Gait, Arms, Legs, Spine The GALS screen aims to find out the following: Are any of the joints abnormal? What is the nature of the joint abnormality? What is the extent (distribution) of the joint involvement? Are any other features of diagnostic importance present?

The key questions Have you any pain or stiffness in your muscles, joints or back? Can you dress yourself completely without any difficulty? (dressing involves all joints) Can you walk up and down stairs without any difficulty? (assesses muscle wasting)

Gait observe patient walking, turning and walking back look for: smoothness and symmetry of leg, pelvis and arm movements normal stride length ability to turn quickly NB: Parkinson an patients have poor arm swing and cannot turn quickly

Arms Ask patient to stand in the anatomical position Check normal girdle muscle bulk and symmetry Check that elbows are straight and in full extension Attempt to place both hands behind the head, then push elbows back (look for glen humeral joint disease) Examine hands palms down, with fingers straight Observe normal suspiration and probation (check for musculoskeletal dysfunction) Observe normal grip (reduced grip  arthritis, MG) Place tip of each finger on to the tip of the thumb to assess normal dexterity and precision grip Squeeze across 2nd to 5th metacarpal (metacarpal ‘squeeze’ test) - discomfort suggests sinusitis

Legs Observe any knee or foot deformity Assess flexion of hip and knee, whilst supporting the knee Passively internally rotate each hip, in flexion Examine each knee for presence of fluid using ‘bulge’ sign and ‘patella tap’ sign Squeeze across the metatarsals to detect any synovitis Inspect soles of the feet for rashes and/or callosities (common in rheumatoid arthritis)

Spine Check par spinal and shoulder girdle muscle bulk and symmetry Look at straightness of spine (look for scoliosis) Check levels of iliac crest (look for hip pathology) Look for abnormal gluteal muscle bulk (look for hip pathology) Check for popliteal swellings (behind the knee) Check Achilles tendons (look for ethsopathy – diseases of bone attachment) Press over mid-point of each supraspinatus and squeeze skinfold over trapezius - tenderness suggests fibromyalgia. Note normal spine curvatures when standing, then ask patient to bend forward and assess lumbar and hip flexion – a straight spine and loss of lumbar flexion suggests enclosing spondylitis Try to place ear on the shoulder each side - tests lateral cervical flexion.

Joint Abnormality Active Inflammation Detailed examination of abnormal joints: Inspection Swelling, redness, deformity palpation Warmth, Crepitation, tenderness movement Active, passive, against resistance Function loss of function

Inflammation of joints Arthritis’ refers to definite inflammation of a joint(s) i.e. swelling, tenderness, warmth and loss of function of affected joints. ‘Arthralgia’ refers to pain within a joint(s) without demonstrable inflammation by physical examination. Commonly occurs with SLE complaining of pain. The main signs of active inflammation include: swelling, warmth, erythema, tenderness, and loss of function of the joint. Site of swelling Tissue involved Indicative of… articular soft tissue joint synovium or effusion inflammatory joint disease

Inflammation of joints Peri-articular soft tissue subcutaneous tissue inflammatory joint disease non-articular synovial bursa/tendon sheath inflammation of structure bony areas articular ends of bone Osteoarthritis Enthesopathy: pathology or lesions of enthesis (the site where ligament or tendon inserts into bone) Examples include: plantar fasciitis, Achilles tendonitis. Irreversible Joint Damage

Joint deformity malalignment of two articulating bones Crepitus audible and palpable sensation resulting from movement of one roughened surface on another classic feature of osteoarthritis e.g. patellofemoral crepitus on flexing the knee Loss of joint range or abnormal movement Dislocation: articulating surfaces are displaced and no longer incontact Subluxation: partial dislocation Valgus: lower limb deformity whereby distal part is directed away from the midline e.g. hallux valgus

Joint deformity Varus: lower limb deformity whereby distal part is directed towards the midline e.g. varus knee with medial compartment OA Theses may be consequence of inflammation, degenerative arthritis or trauma: Identified by Painful restriction of motion in absence of features of inflammation e.g. knee ‘locking’ due to meniscal tear or bone fragment Instability associated with abnormal movement or abnormal range of movement e.g. side-to-side movement of tibia on femur due to ruptured collateral knee ligaments A spinal abnormality such as ankylosing spondylitis is a loss of the lordosis of cervical spine and lumbar spine. This pushes the head forwards, and means that a patient with this condition will be unable to look up.

Distribution of Joint Involvement Determine number of joints involved: polyarthritis> 4 joints involved oligoarthritis2-4 joints involved monoarthritissingle affected joint Note if involvement is symmetrical

Note the size of the involved joints Is there axial involvement? Bilateral and symmetrical involvement of large and small joints is typical of rheumatoid arthritis Lower limb asymmetrical oligoarthritis and axial involvement would be typical of reactive arthritis Exclusive inflammation of the distal interphalangeal joints of the fingers is highly suggestive of psoriatic arthritis

The distribution of the polyarthritis is helpful in the differential diagnosis: Disease Joints involved Joints spared Rheumatoid arthritis PIP, MCP, wrist, elbow, shoulder, cervical spine, hip, knee, ankle, tarsal, MTP DIP, thoracic spine lumbar spine Osteoarthritis 1st CMC, DIP, PIP, cervical spine, thoracolumbar spine, hip, knee, 1st MTP, toe IP MCP, wrist, elbow, shoulder, ankle, tarsal joints Polyarticular gout 1st MTP, ankle, knee Axial

Other Diagnostically Important Features Rheumatoid nodules: collection of normal cells including lymphocytes, and fibroblasts that surround a center of fibrinoid necrosis Tophi: deposit of crystallised monosodium urate in people with longstanding hyperuricemia Psoriasis: the characteristic skin condition may be present on various areas of the skin – commonly the elbows. In Psoriasis, patients commonly have nail “pitting” and also onycholysis – separation or loosening of part or all of a nail from its bed. Malar rash: red/purple scaly rash.

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